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Home My WebLink About20987-z 1~0~ NO. O TOWN OF Sou'rHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PER~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No_N.o 2098? Z Permission is hereby granted to: / .~.~...:.~.~,,~ ...... ~.:. ...... , .......... ..~..,~.~.,~...~.....~..:.¥.:.....~.~.~..F...F.. .......... ,o ..... ~)(~ ~ . at premises located at ....~....~.........~.....~ ...~....t~.....~.., ........ .~.~~ ................... County Tax Mop No. 1000 Section ........ ..O....~...D. ..... Block O ~' Lot No. C~ ..~ pursuant to application dated ............... .~..~,~ xa~-..~. ......... , 19.~.....~ and approved by the Building Inspector. ~tor Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 BOARD OF HEALTH ......... 3 SETS OF PLANS .......... SURVEY ................... CI~ECK~ .................... SEPTIC PORH .............. TEL.: 765-1802 t; o't I P¥ = ^pprov i9 . ee it .................... Disapproved a/c .... ........................... ....../~ 3~}3 2 5 ................................ . (Building Inspector) APPLICATION FOR BUILDING PERMIT Date .... ............. , 19. INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- catign. c. The work covered by this application may not be commenced before issuance of Building PermiL d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws~ Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspectio!ls.. ........ · Ud .' .%., ....... -- (SignatS~fe of applicant, or name, if a corporation) .I2. ~;.~.g~. f.~. . (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........... .~.~. ~v~ ~. :. k~..; !~s..c.c. ............................................................... Name of owner of premises ........................ C~; ;~' ;~e' ;;x' ;;,i ;; i;t;;J~gd}~4~g ' ;~ ~:; If applicant is a corporation, signature of duly authorized omcer CEE: ~.~.:._.g~ .~.~.~. Builder's License No .... O. ~ ............. FO~:~ POL~RED CONC~ErB Plumber's License No ......................... 3. Electrician's License No ....................... BE COMP~.ETE FO~ ALL COP¢STRUCT~O[q SHALL Other Trade's License No ...................... . TNE RffOU~REMEN~LS OF TH~ ~'~E CONoTRHC~ION A ENERGY 1. Locationoflandonwhichproposedworkwillbe'done. ~/~/;~:t;~ES.. NOT RESPONSIBLE FOR ....... ~.~, ............... ?.;.~.0.1~. ~4., ..... ~. ~t~ e~ ...................... llouse Number Street Hamlet County Tax Map No. 1000 Section .................. ~ Block .... ~ Lot Subdivision .......... ~/~ff. ~ .;.~. ~' ......... Filed Map No. ~ff~[ ~[~. Lot...~ ......... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~ ~ ~ ~ ~ ~ b Intended use and occupancy ~ ~ C ~ ' 3. Nature of work (check which apiplicable): New Building .......... Addition .......... Alterotjon .......... Repair ....... ~~al .............. Demolition .............. Other WorX/g..~ .w. ~..,ff. ~.~.. 4. Estimated Cost'tC~.~. . ~:~O~, c~' ,~ (Description) (to be paid on filing this application) 5. If dwelling, number of dwelling units .... ~. ......... Number of dwelling units on each floor~ ................ If garage number of cars 6. If business, commercial or mixed occupancy specify nature ................................................. and extent of each type of use · D~menstons et exmnng structures, if any: Front ............... ,Rear .............. Depth ............... Height ............... ~umber of Stories ........................................................ Dimensions of same structur~ wit;h alterations or additions: Front .............. Rear 8. Dimensions of entire new constrUction: Front ..... .......... Rear....;.;k?[.. ........ Depth ............... Height ............... Number of Stories ..... . ..... 9. Size of lot Front ............... Rear ",,~,t, ......................... 10. Date of Purchase .............................. Name of Former Owner '~ ................ 11. Zone or use district in which premises are situated ......... ".~. '~ · .~ 3.5.-r .................................. 12. Does proposed construction violaie any zoning law, ordinance or regulation: ..,/~.r~ ............ 13. Willlot be regraded .......... i ..... ' .............. 14, Name of Owner of premises./~-/~fi?.~.~. ' "'" .... :,.~... Will excess fill be removed from premises: ~ Yes .N.o. Name of Architect ........... ................ Address ................... Phone No ................ Name of Contractor ........ ~.~.r~ .~ .......... Address ................... Phone No ................ 15. Is this property within 300 feet of a tidal wetland? *Yes ...... · If yes, Southold T~wn Trustees Permit may be require~[ ........ -'. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions ~rop.erty lines. Gl.ye,street and block ntimber or description accerdlng to deed, and show street names and indicatte whether interior or corner lot. STATE OF NEW Y~PvK~ . country OF ..... ul-iSb.\.¢. ..... s.s (Name of individual signing contract) above named. being duI~' sworn,deposes and .·says that he is the applicant et~') .......................... said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this ~pptication; that all statements containedi in this application are true to the best of his knowledge and belief; and that the ,york will be performed in the manner set forth in the application filed therewith. ~wom to before me this ~ ............ g .... of , 19..q.V--- ~otary Public, 6/ ~tOUSBg! ~ ..Sta,~e "~'l~ / ' (Signature of applicant) Term F..xpires May 31, 19